HCG for Tiers

Let's Get Started!

We are very excited to start generating new HCG patient referrals for your practice. Before we can begin developing your new profile website, we need to learn a bit about yourself and your unique practice!For optimal conversion rates and increased web traffic, we strongly recommend providing as much information about your practice as possible. All content submitted should be proprietary to your clinic, and a good representation of your practice.For questions call 800-775-0283 ext. 101.

*All fields with an asterisk are required.

What phone number would you like your incoming patient calls routed to?*

This should be your primary office number so that all calls from prospective patients can be connected to your staff.

What email address would you like your incoming email inquiries from patients sent to? (You may include up to 2.)*

All online consultation requests will be automatically sent to the address(es) specified below.

Your physical office address where you currently see patients.*

We will only market one location per membership, however, we can list your second location on the profile.

Street AddressCityState / Province / RegionZIP / Postal Code

Please check the box below if you have a second location.

Second Location

Address

Street AddressCityState / Province / RegionZIP / Postal Code

During business hours do you have?

Someone actively answering phones

Phone answering service

Name of the clinic.*

Name of the provider.*

Which of the following options should be featured?

Clinic Listed Above

Provider Listed Above

Other Provider

Please list the provider that you want to be featured.*

Biography for the provider(s) - you can copy and paste this information from a document or website.

Provide the mission statement or medical philosophy of the provider or clinic.

List information that makes your HCG diet unique.

For example: tests recommended before starting the diet, supplements recommended to take with the diet, the length of your HCG diet courses, and your patient support process. You can copy and paste this information from a document or website.

How many years has the provider been practicing medicine?*

How many years has the provider been offering HCG to patients?

Approximately how many HCG patients has the provider treated?

How do you administer HCG? Check all the apply.

Injections

Cream

Drops

Other

Are free consultations offered?

Yes

No

Consultations are offered:

In office

Over the phone

What other services are offered?

Do you accept insurance?

Yes

No

Please select one of the following design choices.*

The graphics and headings on these templates are examples and may not be the exact graphics and headings used on your profile website. If you have a preference on graphics that target a specific demographic please let us know.I understand and agree that the template I select will be my FINAL template choice and will NOT be changed at a later date. I understand and agree that I am limited in what I can customize.

Yes, I understand and agree.

*

1.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

Ownership of Intellectual Property and Trade Secrets:By signing our Subscriber Agreement, and completing this New Member form, you hereby acknowledge that you agree to our policies on intellectual property, confidentiality and trade secrets as stated in our agreement. Please refer to these sections of your subscriber agreement for further understanding of our terms and conditions. We are very diligent in enforcing these policies. Please contact us if you have any questions.

I have read and understand the terms and conditions included in my membership agreement.*

Yes

Once your form is submitted it will take our Web Development Department 7-10 business days to build your website and directory listings. Once your website and directory listings are complete, you will be notified via email by our Member Support Team.

We appreciate you taking the time to provide us with the necessary content and information.

We look forward to sending you many new patient referrals for years to come!